Inspection on 23/05/08 for The Glade

This inspection was carried out on 23rd May 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Glade 18/12/08

The Glade 09/11/07

The Glade 16/10/06

The Glade 08/12/05

The Glade 01/06/05

The Glade 12/10/04

The Glade 20/04/04

The Glade 27/11/03

The Glade 15/07/03

The Glade 18/02/03

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Glade, The 32 Lancaster Road Southport Merseyside PR8 2LE Lead Inspector Mrs Margaret Van Schaick Unannounced Inspection 23rd May 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glade, The Address 32 Lancaster Road Southport Merseyside PR8 2LE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01704 566699 01704 566698 No email Mr David Winston Jackson Mrs Susan Jackson Mrs Antonia M Gillett Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 25 in the category of OP The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection 9th November 2007 Date of last inspection Brief Description of the Service: The Glade is an older property that has been converted into a care home and is registered to provide personal care and support for up to 25 older people. It is situated in a leafy part of Southport close to public transport and within easy reach of the amenities that serve the area. The home provides accommodation over four floors and has lift access. The communal space contains one large dining room and one large sitting room. Toileting and bathing facilities are located throughout. The home has had adaptations such as handrails, hoists, specialist bathing facilities and ramps to suit the needs of the residents. There is a call-bell system throughout the home. The front garden is accessible via a ramp and suitable garden furniture is available for the residents and their visitors. The Glade is part of a small group of homes privately owned by Mr and Mrs Jackson and is managed by Antonia Gillett. Weekly fees range from £379-£480. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. A site visit took place as part of the unannounced key inspection. It was conducted over a one-day period for the duration of 9 hours. Eighteen residents were accommodated at this time. As part of the inspection process all areas of the home were viewed including most resident bedrooms. Care records and other residential home records were viewed. Discussion took place with residents, staff and visiting relatives. The inspection was conducted with Mrs Antonia Gillett, registered manager. Discussion also took place with the deputy manager, care staff, cook and with the registered provider Mr David Jackson. During the inspection 2 residents were case tracked (their care files were examined and their views of the service were obtained). All of the key standards were inspected and also previous requirements and recommendations from the last inspection in November 2007 were discussed. Satisfaction forms “Have your say about….”were distributed to a number of residents, relatives and staff prior to the site visit. A number of comments included in this report are taken from surveys and from interviews. An AQAA (annual quality assurance assessment) was completed by the manager prior to the site visit. The AQAA comprises of two self-assessment questionnaires that focus on the outcomes for people. The self-assessment provides information as to how the manager and staff are meeting the needs of the current residents and a data set that gives basic facts and figures about the service including staff numbers and training. What the service does well: The Glade has a warm and friendly atmosphere and public areas are pleasantly decorated in a domestic style. One resident who was interviewed for their views stated, “It’s a first class hotel and they do care”. Staff were observed chatting to residents in a respectful and friendly manner. Other residents interviewed were equally complimentary about the staff and stated, “staff are Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 6 terribly sweet, they help me get dressed and leave my room nice and tidy”, “I couldn’t criticise this place, and the staff are fabulous”. The assessment process is effective and ensures that resident needs are identified prior to admission and reviewed during their stay. The changing needs are recorded on care files. Families and residents were asked about their views with regard to the admission process. One relative stated, “Mum settled in very well and is getting used to being away from home”. A resident stated, “I did not want to leave my own home but I have settled in quite easily, they are all very nice”. Residents needs are met through an individual care plan that identifies and addresses all of their health, personal and social care. Residents and relatives interviewed were happy with how their care needs were being met. Residents and their families also confirmed that they were consulted and kept up to date with the support and care required to meet their individual needs. One relative stated, “I have spoken to the manager many times about Mum’s progress, she is well looked after”. One resident confirmed the care staff had gone through her care plan”. Residents are encouraged and supported within their ability to live their lives as they wish. Activities are arranged to suit the residents varying needs and includes regular bus trips. One resident interviewed stated, “I have been on four bus trips, which include Chorley, a mystery tour, Crosby and Lytham St Anne’s. The induction and training programme ensures that care staff has the necessary skills needed to care for the residents. Residents interviewed were happy with how staff assisted and supported them. Residents interviewed stated, “staff make quite a fuss of me”, and “all of the staff are very nice”. The management of the service and key records ensure the health, safety and welfare of the residents. What has improved since the last inspection? Residents and their families are confident that any concerns they raise are dealt with promptly and to their satisfaction. The manager meets with the residents and families on a daily basis when she is on duty. This ensures any concerns residents or relatives have are addressed and dealt with promptly. The improvements to the service ensure residents have a pleasant and homely environment to live in. On the ground floor the two bathrooms have been fully refurbished adding additional new equipment to enable all residents to access bathing, shower and hairdressing facilities. Many of the resident bedrooms have been refurbished also with new décor, soft furnishings and bedding. The bedrooms are colour coordinated therefore providing a pleasant environment for residents who live there. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Op 3 & 6 was assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process is effective and ensures that resident needs are identified prior to admission and reviewed during their stay. EVIDENCE: The manager or deputy visits the prospective residents prior to admission to the service. These visits are carried out at home or hospital. Prospective residents are invited to visit the service for lunch prior to admission. Relatives and residents interviewed confirmed that they were visited prior to admission. One resident stated, “Antonia visited me in my home in Southport, I like it here, although I didn’t want to leave my own home, I’ve settled in quite easilythey are all very nice”. Care files also evidenced where and when the assessment took place. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 10 Families surveyed about their relatives’ pre admission process gave a positive response. One relative interviewed stated, “mum is settling in very well she is getting used to being away from home”. The assessment documentation of two residents was viewed and this evidenced a full assessment was carried out for both residents. The assessment covered many areas including medication, allergies, mobility, skin, pain, diet, mental health, previous medical history, personal care, social interests/hobbies and communication. Details of family and friend contacts and relationships were discussed and recorded. Likes, dislikes and personal preferences about how they like to live their lives including daily routine. The assessment documentation is clear and fairly detailed. Needs are reassessed during the residents stay and care documentation evidences this. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10 was assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents needs are met through an individual care plan that identifies and addresses all of their health, personal and social care. EVIDENCE: As part of the case tracking process two of the residents care files were examined. The care plans were commenced on admission to the service. These were based on the information collated during the assessment process. Both care plans evidenced the care and support to be provided by staff. Additional information with regard to health and social care needs is documented on care notes. Areas covered also include aids that may be used by residents including hearing aids, spectacles and walking aids. Other health professional input/intervention is recorded on care files and these include, chiropody, dental care, district nurse and GP visits/advice. Residents and relatives interviewed confirmed they received regular input from health professionals. One relative stated, “I think she has seen the Doctor, she has new glasses now and seen the chiropodist”. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 12 Care plans are reviewed monthly or sooner. Following discussion with residents some were aware of their care plans and there is evidence of their involvement or their relatives in care files. One resident interviewed confirmed staff had discussed her care and stated, “care staff have gone through my care plan”. Care reviews are also carried out for individual residents 6-12 monthly dependent on the residents needs and progress. Residents and their families where wished are involved in this process. Evidence of resident and family involvement is recorded on care notes. One relative interviewed stated, “I have spoken to Antonia (manager) many times and discussed mum’s progress and I think she has seen the Doctor. Mum has new glasses and seen the chiropodist. It was evident through examination of care plans and documentation the service has improved how it records information throughout a residents stay. Relative interviews confirmed care needs are met and were needed advice/intervention is sought from health professionals. A detailed social assessment and brief personal history including hobbies/social needs is also in place. Residents are encouraged to maintain their independence where possible. Risk assessments are in place with regard to mobility and risk of falls. These are reviewed monthly as evidenced. Residents were observed to be walking around the service independently or with support of staff or walking aids. Residents have exercise classes to maintain their present mobility. Nutritional assessments and weights are recorded and where needed dietary advice is accessed from the dietician. Pain is assessed prior to admission and the management of any pain is recorded on care files. Emotional needs, social interests, resting and sleeping and spiritual needs are addressed as evidenced on care files. A daily record evidences the ongoing record of care provided to residents. Residents and relatives were generally positive about the care provided by staff with one relative stating, “Mum is well looked after”. The management of medication has improved. There have not been any reports of any problems. The monthly medication records are clear and easy to follow. Medication is carried forward. Some prescribed supplementary drinks were out of date and the inspector advised they be disposed of by the usual procedure. There is a controlled medication cabinet in place. Controlled medication records are kept. Some petty cash was stored in the controlled cupboard therefore staff were advised to ensure this was kept secure elsewhere. All medication ‘rounds’ were signed for. One of the residents self medicates therefore a risk assessment needs to be in place to ensure medication is taken as prescribed. The medication trolley is secured to a wall and the service also Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 13 has a secure storeroom for storage of other medication and waste medication awaiting collection. Procedures and records are in place for returns of unused medication. The local pharmacist carries out regular audits of medication with individual records for each resident evidencing this. Staff was observed delivering some of the care during the visit. Staff was noted to be discrete, kind and respectful towards residents. Through discussion with residents, this is generally the normal behaviour of staff. Most of the residents were complimentary about the staff during discussions/interviews of residents. Residents interviewed were complimentary about the support provided to ensure care needs are met. Their statements included, “It’s a first class hotel and they do care” and “I like it here”. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Op12, 13,14,15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported within their ability to live their lives as they wish. EVIDENCE: Residents were observed using the sitting room and dining room during the visit. Some of the residents use the sitting room for watching television or general communication with others including visitors. Other residents who prefer their own company spend more time in their bedrooms, except for activities where they may join in with the other residents including going out in the mini bus. Some of the residents go out independently. Others go out with their relatives as confirmed through interviews with residents and families. Holy Communion is available on a regular basis to residents who wish to participate. This was confirmed through discussion with residents and staff. One of the residents stated, “I am religious and attend regular communion”. A list of activities for the week is on display. There are various activities on offer for residents and some of the residents were able to discuss the activities available. One resident stated, “I have been on four mini bus trips. Chorley, a Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 15 mystery tour, Crosby, and Lytham St Anne’s”. Other activities include regular bingo, quiz’s, crafts, outside entertainers, music, films, girl guides visits and exercise classes. The service also arranges parties throughout the year to celebrate various occasions as confirmed by residents. There is also a gardening club twice a month, which residents really enjoy. One resident isn’t keen to join in and stated, “I don’t join in with the activities, I like to read, I enjoy my own company” and this is accommodated. The service has an open visiting policy-with residents and relatives confirming this through discussion. Relatives and visitors to the service were observed on the inspection day. Relatives and residents confirmed that they were made welcome by staff with no restrictions on visiting. Residents stated, “my family can visit anytime, they just walk in” and “visitors can come when they wish and are made to feel welcome, they are always given a cup of tea and a biscuit/bun to eat”. A relative stated, “we can visit at any time the staff make you welcome”. Residents in general are encouraged to maintain a lifestyle they are happy with and within their abilities and healthcare needs. One resident stated, “I go up to bed when I want and get up in the morning when I want to. Another resident stated, “”I go to bed at 6.30pm it’s a matter of choice, I sometimes have a coffee with brandy and put myself in bed”. One resident stated, “I like to take my breakfast and other meals in my room, I prefer that, I sometimes mix with other residents when I play bingo. Residents interviewed confirmed that staff assists them with their personal care and one resident stated, “staff are terribly sweet and help me get dressed”. Meals are served to residents in the dining room and in resident bedrooms if this is their wish. A menu was available for a four-week rota. There were no choices for the main course on the menu but residents interviewed confirmed there were choices. Residents interviewed stated, “the food is marvellous and yes you have a choice”, “the food is okay, fish, and peas and mash and custard and cake for lunch today”, “you have a cup of tea when you want to” and “the food is very good, we do have a choice we had salmon today”. Residents confirmed that the cook speaks with them daily to see if they are happy with the meals available each day. When residents are not an alternative is cooked. The cook and manager were advised to ensure alternatives were offered on the printed menu. Today’s menu was printed onto the large board in the front hall for residents to see. A choice was available. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): OP16, 17 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families are confident that any concerns they raise are dealt with promptly and to their satisfaction. EVIDENCE: The service has a clear complaints procedure in place. Residents canvassed for their views confirmed they understood it. The complaints log was viewed. There are no complaints on record since the last inspection. The manager stated, “there have been no complaints since the last inspection in November 2007”. Through discussion with the manager it is apparent that she meets with residents and sees visitors to the service on a daily basis when she is on duty. The manager then is able to deal with any minor concerns that residents or their families have. Feedback from relative surveys confirmed any concerns are always addressed when raised. One relative stated, “I have no concerns or complaints at all”. None of the residents interviewed had any complaints. One resident stated, “I have no complaints at all”. Care staff has attended adult protection training and through discussion with some of the staff they confirmed they are familiar with the new Sefton procedures. Care staff provides support to residents and their relatives during postal voting to ensure residents who wish to can vote. One of the residents visits the local ballot box to vote. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 17 Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP19, 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The improvements to the service ensure residents have a pleasant and homely environment to live in. EVIDENCE: During the inspection visit most areas of the service were viewed including residents bedrooms. Many of the bedrooms have been refurbished to include new décor, furnishings, carpets and bedding. Residents interviewed were very pleased with the changes and complimentary about the improvements. One resident interviewed stated, “I have no complaints it’s the best room in the house”. Another resident stated, “I like my bedroom, I was in a smaller one and didn’t like it so they gave me this one”. The two ground floor bathrooms have been completely refurbished with matching white suites. A parker bath (for residents who have mobility Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 19 problems) is also included. A specialist hairdressing basin is also fitted for easier access when residents have the hairdresser. The tiles on the front steps have been replaced and maintenance records evidence regular checks are carried out. Any work that needs doing is recorded on the work sheets and the maintenance person carries out the work and signs. The public areas and residents bedrooms were clean and tidy. Residents interviewed confirmed they were satisfied with the cleanliness of the service. Residents stated, “the home is clean and the laundry service is good”, “they leave my room nice and tidy, it’s nice” and “my room is cleaned every day”. One relative stated “the laundry is ok yes Mum’s clothing is clean but one or two things get lost”. The environmental health officer carried out a routine visit earlier this year and was satisfied with the kitchen with no recommendations made. The kitchen when viewed was clean and tidy. There are records of hot food temperatures and fridge/freezer temperatures. The storeroom fridge/freezer temperatures were not on record. The cook confirmed she had not recorded them therefore was advised to do so. The cook confirmed she is happy with her budget for food. The laundry room is situated in the basement and contains sufficient equipment for the service needs. Hand washing facilities, paper towels and a soap dispenser is available for staff. Garden furniture suitable for residents with canopy protection for the sun was in place in the front garden Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, 28,29,30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The induction and training programme ensures that care staff has the necessary skills needed to care for the residents. The recruitment process needs to be ‘tightened up’ to ensure all pre employment checks have been completed fully. EVIDENCE: The staffing rota was viewed and evidences all staff employed. Sufficient care staff was on duty on the day of inspection. Senior care staff is allocated to each shift including night duty. Eight of the care staff has completed NVQ level 2 and two have commenced this level. Two of the care staff has the NVQ level 3 and two have commenced. This is evidenced through staff interviews and training certificates. The NVQ training uptake is exceeded in this standard. The deputy manager has commenced NVQ Level 4. Staff employed in the service have two files, one for personal information and the other records training attended. Staff files are well organised and evidence pre employment checks are carried out. Personal details including application forms, references, start dates, staff supervision, contracts and police checks are carried out. One of the new staff files was missing part of the police check from January 2008. The service had not received confirmation that the check Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 21 had been completed. The manager resolved this problem following the inspection visit. The service need to ensure all checks are in place before staff work with residents unsupervised. One of the references viewed was a verbal record. The manager was advised to ensure this is followed up with a written record. All other checks had been carried out. A training programme is in place for all staff to attend. All staff has an individual training and development file. The ‘skills for care’ induction is evidenced in staff training files. Certificates evidence previous training attended. Further training needs has been identified for individual care staff. Staff training attended includes manual handling, fire, basic food hygiene, first aid, health and safety, medication, protection of vulnerable adults and abuse. The Aqaa states that policies and procedures are available to address equality and diversity in the service. The service have identified that further training is to be sought for staff therefore this would benefit them and the residents in their care. The induction includes: principles of care, safe working practice, organisation and worker role, needs of residents, policies and procedures also re infection control, confidentiality, cosh, fire, food record keeping, health and safety, manual handling, accidents and emergencies and responding to abuse. Staff interviewed confirmed they attended an induction programme on commencement of employment. One staff stated, “I had an induction with Sarah (deputy manager), it was a good induction and on my first day I was given a tour of the home”. Another staff interviewed stated, “I had an induction with Antonia (manager) it lasted 2 weeks, it was a good induction”. Staff employed in the service confirmed through discussion that they enjoyed working in the service. One member of staff interviewed stated, “I enjoy working here, there is enough staff at present and the care for residents is fairly good. I would like to spend more time with residents”. None of the staff had any concerns about how care staff meets the needs of the residents. Another staff stated, “staff are kind to residents from what I have seen and I have been happy working here”. Residents were positive in their comments about staff employed in the service and stated, “staff are mostly good, they are kind to me”, “the staff are fabulous”, “all staff are very nice they make a fuss of me” and “they are all very nice, the staff on nights are nice too”. Families interviewed were complimentary about how staff cares for their relatives. Relatives interviewed stated, “my mum is happy with the staff I have no complaints”, “they are very kind and patient staff” and “the staff are excellent, they are very respectful to all residents and visitors”. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,33,35 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the service and key records ensure the health, safety and welfare of the residents. EVIDENCE: The deputy manager supports the registered manager in her role. The manager has the RMA (Registered Managers Award) and the deputy has almost completed her award and is waiting for the certificate to confirm she has been successful. The manager has continued to keep herself updated by attending all mandatory training. Through discussion with the manager it is evident that she has a good understanding of how illness can affect the older person. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 23 Residents interviewed were complimentary about the management of the service. One resident stated, “Antonia and Sarah are super”. Relatives interviewed stated, “I am able to talk to Sarah and Antonia if any worries” and “I find the manager approachable and have met Mr Jackson many times, he is very nice and pleasant with everyone”. One relative commented, “it’s an excellent service and very well organised”. The service canvasses the views of relatives and residents by distributing questionnaires with the results of these published. The inspector viewed some of the completed questionnaires and noted the responses were positive. The manager also holds regular residents meetings with the minutes from February 08 published. The minutes identify the residents who attended the meeting and areas discussed. Staff meetings are also held with minutes published. The individual financial records of two of the residents’ monies were viewed and records kept were clear and showed no discrepancies. Although Mr Jackson visits the service regularly the most recent providers recorded visit is from October 2007. Mr Jackson was present during part of the inspection and advised that he had recently completed a report. Accident records are completed correctly. These were viewed during the visit. The Aqaa states that all servicing of all equipment held in the service is up to date. Some of the servicing details and certificates were viewed and confirmed checks are carried out and servicing completed. The fire logbook was viewed. Various fire alarm points and emergency lighting is checked weekly. Staff attendance at fire training is in place and up to date. A weekly audit is carried out of the building and bedrooms. The most recent weekly audits carried out in May 2008 were viewed. The service has been audited and the manager has advised the owners of areas of the service that require attention. Liability insurance is in date. The lift has been completely refurbished and servicing has been carried out also this year. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP9 OP9 OP9 OP15 OP29 OP30 OP30 Good Practice Recommendations It is recommended that risk assessments should be in place for residents who self medicate. It is recommended that out of date supplementary drinks should be disposed of according to the medication procedures. It is recommended that petty cash should not be stored in the controlled drugs cabinet. It is recommended that the written menu should evidence choices at mealtimes. It is recommended that all pre employment checks should be tightened up. It is recommended that verbal references should be confirmed in writing before an employee commences work. It is recommended that equality and diversity training should be provided for all staff. Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glade, The DS0000005322.V362668.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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